Antibiotics

Airway and Breathing

Oxygen
Clinical assessment is determinant of need for ventilation, but need for 60ml/kg fluid in first hour is indication forintubation.
40% of cardiac output is used to power work of breathing – intubation and ventilation can reverse shock.
Ketamine plus NMJ blocker recommended for intubation.
Other induction agents may cause a fall in BP (Propofol, sevoflurane, thiopentone)
Pre-load with volume.
Consider concomitant IV inotropes peripherally to cover intubation

Monitoring

Fluids

Requirement for boluses may be required for days – direct against endpoints

Crystalloid (normal saline, Hartmann’s)

If Hb < 10g/dL, give blood

If coags abnormal give FFP – but not as a push bolus

Once resuscitated from shock, consider diuretics or CVVH if >10% fluid overloaded and not maintaining losses adequate to achieve a negative balance.

Cold normotensive shock

Normal BP, high SVR, low CIMilrinone or glyceryl trinitrate or nitroprussideNoradrenaline may become necessary as vasodilation occurs
Volume requirement may also increase

Warm shock

Low BP, low SVR, low CI
Noraderenaline
Vasopressin 2nd line

Refractory cold shock

Consider additional diagnoses:

Problem

Treatment

Pericardial effusion

Drain

Pneumothorax

Drain

Hypoadrenalism

Hydrocortisone

Hypothyroidism

Thyroxine

Ongoing fluid losses

Replace losses

Increased intra-abdominal pressure

Drain

Necrotic tissue

Surgery

Immune compromise

Consider GCSF, Immunoglbulin

ECMO may be considered if all else failing – chance of survival 50% or less.

Thresholds

Age

Heart rate bpm

Perfusion pressure (mean arterial pressure – CVP) mmHg

Term newborn

120-180

55

Up to 1y

120-180

60

Up to 2y

120-160

65

Up to 7y

100-140

65

Up to 15y

90-140

65

Algorithm

Controversies

FEAST study

This study published in 2011 appears to demonstrate an increase in mortality in setic shock in patients receiving aggressive fluid resuscitation. However, the population studied was very different form that encountered in the UK, and the provision for PICU was extremely limited, so no firm conclusions can be drawn. There is no recommendation that current practice should change.

Fever management

There are theoretical reasons why fever may be helpful in fighting infections – not least because it has evolved as a response to infection. There is evidence that viral replication may be impaired by higher temperatures. On the other hand, control of high temperatures may have metabolic advantages in reducing oxygen consumption. An observational study in adults in 2012 demonstrated an association between paracetamol use and mortality, but other studies have produced conflicting results. As yet, there is no compelling reason to stop antipyretic treatment in sepsis in children.

Steroids in sepsis

Evidence form adults has suggested that treatment with hydrocortisone may be benificial, but there is no clear consensus in children. Below is the policy for our PICU.

To be considered as a rescue therapy by the PICU Consultant in patients with:

Septic shock and

Ongoing fluid requirement and

Increased inotropic support

Perform a random Cortisol level prior to commencing steroids

Hydrocortisone (HC) should be used rather than Dexamethasone

There are no indications for high dose steroids in sepsis

Stress doses should be used: HC 30 mg/m2/day IV divided 6 hourly

Stop steroids if Cortisol level >500nmol/l

Steroids should be weaned once patient has improved and off inotropes

Involve endocrinology if any suspicion of adrenal insufficiency as an underlying diagnosis.

A normal stress response in meningococcal disease is a CORTISOL VALUE ON ADMISSION > 950 NMOL/L.